For Your Records

Hi ROBERT,

Thanks for choosing CVS Pharmacy^®. This email contains a record of your recent vaccination.

If you’re 18 or older, you can view this and other CVS Pharmacy or MinuteClinic health records in your health dashboard. To access vaccination records for a minor, you first have to add them to your account by requesting to manage their prescriptions through your pharmacy dashboard.

View Record

Vaccine administration record

Patient information

Last name:

First name:
ROBERT

Date of birth:

Gender:
M

Address:

Phone:
my-Oakland-voicemail-number

Primary care provider (PCP):
JENNIFER BARON

PCP address:
123 DI SALVO AVESTE A
where-I-live 951281717

Vaccine administration information

Vaccine type:
Shingles (Shingrix)

Vaccine administered:
SHINGRIX VIAL KIT

Administration date:
02/25/2022

Manufacturer:
GLAXOSMITHKLINE

Lot #:
A45FG

Expiration date:
04/2023

Route:
IM

Site:
Left Deltoid

Volume (ml):
0.5ml

Vaccine Information Statement version date:
10/30/2019

Date Vaccine Information Statement given to patient:
02/25/2022

Verifying pharmacist:
Yu, Whitney
Signature electronically captured

Administering immunizer name and title:
Yu, Whitney, RPh

Vaccine prescriber:
ARMAGHAN AZAD

Vaccine prescriber address:
4980 BARRANCA PKWYSTE 170
IRVINE, CA 926048652

Store information

Store #:
17176

Rx #:
0165186

Address:
533 COLEMAN AVE
where-I-live 95110

Phone:
(408) 346-2023

Need a more detailed record?

The summary above and online may not include complete information or serve as proof of vaccination in some states. If your state needs more details, try the following options:

If you signed a vaccination consent form on paper, we gave you a paper copy of your official Vaccine Administration Record
If you gave us your primary care provider's information, contact them for a copy
See if your state has an immunization registry
Call CVS Pharmacy

Report side effects and help keep the vaccine safe

The CDC has created a way for you to report how you feel after the COVID-19 vaccination through a smartphone-based tool that uses text messaging and web surveys to check in with you.

How was your vaccine experience?

Take 1 minute to rate your vaccination experience with CVS Pharmacy and share your thoughts.

Consent for services

CONSENT FOR SERVICES: I have received and read (or had read to me) the Vaccine Information Statement(s), Vaccine Information Fact Sheet(s) and/or Patient Fact Sheet(s) regarding the vaccine(s). I understand the benefits and risks of vaccination. I voluntarily assume full responsibility for any reactions or consequences that may result. I understand that I should remain in the vaccine administration area for 15 minutes, or longer if directed, after the vaccination to be monitored for potential adverse reactions. In the event of side effects, I understand I should call the pharmacy, my doctor, or 911. I certify that the information provided regarding eligibility for the vaccine is accurate and request that the vaccine be given to me or to the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so. Please note the following must have the consent of a parent or guardian: Patients in Alabama/Nebraska under 19 years old; patients in South Carolina under 16 years old; and patients under 18 years old in all other states. If I am receiving a COVID-19 third dose, I attest that I am eligible for that dose because I am immunocompromised. State of Georgia only: I verify a pharmacist asked for my health history and whether I have had a physical exam within the past year. Health care providers did not identify conditions(s) that would mean I should not receive vaccine(s).

AUTHORIZATION TO REQUEST PAYMENT: I authorize CVS Pharmacy^® ("CVS^®") to release medical information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to CVS. I certify that the information provided about my Medicare, Medicaid or other coverage is correct.

ACCEPTANCE OF FINANCIAL RESPONSIBILITY: Notwithstanding anything previously set forth, I agree that I am responsible for and will promptly pay on demand any and all obligations to CVS Pharmacy including all self-pay balances as well as those charges for services not covered or disallowed by my insurance carrier (For non-COVID-19 vaccines).

DISCLOSURE OF RECORDS: I understand that CVS^® may be required to or may voluntarily disclose my health information with respect to this vaccine to my healthcare providers, my insurance plan, health systems and hospitals, and/or state or federal registries. I understand that CVS will use and disclose my health information as set forth in the CVS Notice of Privacy Practices (copy is available in-store, online or by requesting a paper copy from the pharmacy). State of Ca only: I agree to have the Ca Immunization Registry (CAIR) share my immunization data with health care providers, agencies or schools. State of FL only: Students 18-23 may opt out of the immunization registry by notifying pharmacy prior to administration Vaccine Clinics: If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.

Signature electronically captured

Consent date: 02/12/2022

Screening questions

Are you sick today? (For example: a cold, fever or acute illness)

Do you have allergies or reactions to any foods, medications, vaccines or latex? (For example: eggs, gelatin, neomycin, thimerosal, etc.) or have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital? If yes, what are you allergic to?

Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?

Have you had a seizure or a brain or other nervous system problem or Guillain Barre?

Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?

For Tetanus vaccines, do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?

Are you currently pregnant or breastfeeding or is there a chance you could become pregnant during the next month?

Do you currently or have you in the past 14 days, had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?

Have you tested positive for COVID-19 within the last 14 days?

Are you moderately/severely immunocompromised from a medical condition/immunosuppressive therapy, including/not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteroids/other immunosuppressive/immunomodulatory biologic agents?

Pharmacist notes:

Patient's Temperature: 96.1f